Shoulder Orthopedic Surgery Safford AZ

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Young athletes are twice as likely to dislocate the shoulder compared to the general population. What's the best way to approach this problem? When is surgery needed? These are just two of the many questions answered in this update on first-time shoulder dislocations.

The authors did not study a specific group of patients. Instead, they reviewed current information on pathoanatomy (what happens in the shoulder) and etiology (causes of dislocation). The need for a quick and accurate diagnosis that leads to a plan of care is established. The benefits of imaging studies are presented. And options for both conservative (nonoperative) care and surgical management are presented. Here's a closer look at each of these topics.

Most first time shoulder dislocations are anterior (forward direction). The structures around the shoulder (e.g., ligaments, capsule, muscles) are designed to prevent dislocations. But with enough force and with the shoulder in just the right position, these safeguards can be overcome.

Younger patients are more likely to end up with a labral tear. Injury in older adults is more common because of degenerative changes of the rotator cuff associated with aging. The labrum is a tough rim of cartilage around the shoulder socket. The rotator cuff is a group of four muscles and tendons that surround the shoulder. Both of these anatomical structures help hold the shoulder stable and in place. A torn anterior-inferior (front/lower) labrum and joint capsule is called a Bankart lesion. Bankart lesions are very common in all anterior shoulder dislocations.

Most young athletes with their first shoulder dislocation are examined either on the field at the time of the injury or some time later in the emergency department. Some experts advise having an X-ray before trying to reduce the shoulder. Reduce means to put the shoulder back in the socket. Usually, the person is in so much pain, a closed (without surgery) reduction seems like the right thing to do. But there could be other injuries that need attention and that could be made worse by a closed reduction.

X-rays confirm the direction and severity of the dislocation. Any bone fractures present will show up on an X-ray. Other clinical tests may be performed to assess nerve, blood vessel, and soft tissue structures. If more details are needed, a CT scan and/or MRI may be ordered. MRIs with a dye injected into the joint can show the location and size of a labral tear.

Once the exam is completed, the surgeon can decide on the best plan of care for that patient. Reducing the dislocation is the first step. Sometmes this can be done without surgery. A special method called the Stimson technique can be used. A numbing agent is injected into the joint. Once the patient is pain free, he or she lies face down on an examining table. The injured arm hangs over the edge of the table. A weight tied to the forearm can pull the head of the humerus down, so it can pop back ...

Six Orthopedic Surgeons Around the World Discuss Challenging Cases

Some shoulder problems are so complex and so difficult, it's not even clear that surgery can help them. This may be the case with massive rotator cuff tears, shoulder instability, adhesive capsulitis (frozen shoulder), revision arthroscopic stabilization surgery, and other tendon injuries.

In this article, six orthopedic surgeons from around the world offer their opinions and expertise for these challenging conditions. Dr. Tonino from the United States, Dr. Gerber from Switzerland, Dr. Itoi from Japan, Dr. Porcellini from Italy, Dr. Sonnabend from New South Wales, and Dr. Walch from France offer insights, patient photos, and ideas for evaluation and treatment of these complex shoulder disorders.

Each patient must be examined and considered on an individual basis. Imaging studies such as MRI and arthroscopic exam help with the decision-making process, but the surgeon can't just rely on the results of those tests to find the optimal treatment for each problem. It's also important to consider why the patient has the problem in the first place.

For example, if there is a chronically dislocating shoulder, is it because a previous stabilization surgery failed? And if so, why did it fail? Were there surgical technical errors or other undetected injuries that affected the outcome? Was there some bony deformity, soft tissue imbalance, or other anatomical reason why this patient didn't get a positive result from the previous surgical treatment?

If surgery is considered (perhaps for a severely frozen shoulder or massive rotator cuff tear), then the surgeon must put on his or her detective hat in making a preoperative assessment. Careful evaluation is needed of pain levels, shoulder motion, strength, and function before deciding on type of repair.

The surgeons say there's no sense in attempting a repair of massive rotator cuff tears when the patient meets any of these three criteria:

Unable to hold the shoulder in a position of external rotation

Unable to lift the arm up overhead (especially if the shoulder dislocates during this movement)

Presence of a second injury involving damage to the deltoid muscle (an important mover and stabilizer of the joint)

In some cases of irreparable rotator cuff injuries, surgery can be done to improve the patient's situation, even if a complete repair can't be done. The surgeon may decide to débride (carefully scrape) the frayed or torn edges of a tendon and/or muscle, perform a tendon transfer to help substitute function of an irreparable tendon, or try a partial tendon repair with a tendon transfer.

When it comes to atraumatic shoulder instability (chronically dislocating joint without prior injury), the authors suggest looking at a couple of different things. First, where does the instability occur: is it when the patient is halfway through the motion or at the end of the shoulder joint's range-of-motion?

This gives the surgeon some idea of how lax (loose) is the joint. Each ti...

Surgeons Advice on Shoulder Fractures When Evidence is Lacking

Medicine has taken a decided turn toward demanding evidence that a treatment technique or approach is the right one to choose for each problem. Evidence-based medicine also addresses the specific needs of each patient who happen to have that problem. But what should be done when there isn't enough evidence to know which way to go? And when there is more than one way to go?

That's the dilemma facing surgeons treating patients with complex shoulder fractures -- ones that break the bones into three or four pieces. The question is: which works better -- open reduction and internal fixation (ORIF) or shoulder replacement? And if a shoulder replacement is needed, should that be a hemiarthroplasty, a total joint replacement, or a reverse arthroplasty?

A hemiarthroplasty means only one part of the joint is replaced (either the round ball in the socket or the socket). And a reverse arthroplasty describes an implant with a ball-shaped head where the socket used to be and an artificial socket where the round head of the humerus (upper arm bone) was once located.

When selecting the right shoulder implant to use, the decision-making goes even one step further. In each of the replacement categories, there are many different designs (styles, materials) of implants to choose from. The same goes for hardware used in the ORIF. The surgeon must decide whether to use locking and nonlocking plates, pegs vs. screws, and rotator cuff sutures vs. no sutures.

Regardless of the treatment approach enlisted, there are many factors to consider such as patient age, health, blood supply to the shoulder, bone health, and joint mechanics. That's why there haven't been enough studies comparing each type of implant with patient characteristics and outcomes to guide the surgeon.

The authors of this study use the three-part shoulder fracture of an active 55-year- old man to walk us through the decision of ORIF vs. arthroplasty. There was a three-part fracture of the upper humerus. The neck of the humerus was also displaced (the fracture separated and shifted apart). Fortunately, there was good bone quality and good blood supply. No nerve damage occurred as a result of the displacement of bone (jagged edges can sometimes cut into nearby tissues).

Open-reduction and internal fixation (ORIF) is preferred for younger, active, healthy patients. But the surgeon must be able to reduce the fracture (put it back together and hold it there). If the gap between the pieces of bone is too much for the body to fill in on its own, bone grafting may be used. Otherwise, it may be necessary to go to Plan B (replace instead of repair).

Anyone under the age of 60 should at least be considered for ORIF as part of Plan A (repair as the first line of treatment). Older adults (especially over age 80) and anyone with a degenerated or previously torn rotator cuff may be a better candidate for a reverse arthroplasty. Age isn't the only cut-off used when choosing between...

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